This is a report about obesity, just published by the Bipartisan Policy Center ( @BPC_Bipartisan), that I have been anticipating ever since I had the pleasure of sharing the stage with people from across industries and institutions with the ability to change the trajectory of obesity in the United States (see my posts and presentations on that experience here – it really did blow my mind in terms of what’s possible)
The image on the right, taken from the report sums up quite well the difference between a social determinants model of improving health, and an individually directed one. If you go even deeper than the info graphic, though:
In sum, considerable empirical evidence exists to suggest that where people live and work has a much greater impact on their health than their interactions with the health care sector or their genetic makeup.
…individuals and parents, who ultimately make the decisions and set the examples that influence not only their own health but that of future generations… at the level of communities and key institutions, including government. These institutions shape the environment in which individual and family decisions get made and they can help bring about the broader changes needed to ensure that all Americans—including especially vulnerable citizens—have access to information and options that support and encourage healthy choice.
Since the United States’ health care system is not tied to the social care system the way it is in many European countries, the way to alter the “causes of the causes” (the other way to refer to social determinants) of poor health (such as obesity), is not through changing the social fabric, it’s through partnership and collaboration, which is why this report is extremely helpful.
This report talks about what can be done in our society, which includes everything from changes in our medical education system to market driven changes in large employers, the hospitality industry, and hospitals, with plenty of examples of private and governmental approaches. If you’re interested in social determinants of health and don’t know where to start, start here.
- Existing national dietary guidelines apply to children and adults ages two and up; activity guidelines at age 6 and up, missing the most critical times in a person’s health development (The “first thousand days” – from pregnancy to age 2 )
- The United States is the only developed country that does not comply with the WHO International Code of marketing of Breast-milk Substitutes; there is now a Baby Friendly certification that hospitals may obtain which includes avoiding the use of formula where not medically necessary (There are 143 US hospitals certified to date, Kaiser Permanente and Indian Health Service have made the Baby Friendly commitment)
- The DC Healthy Schools Act of 2010 is a model for other communities; it mandates that students have at least 30 minutes to eat their meals, provides funding for using local produce, and requires that schools provide physical education and activity through all grades.
- There isn’t a catalog of workplace wellness programs that includes best practices and cost-benefit analysis (e.g. no “Innovations Exchange” for workplace wellness, however there is a Community Guide supported by the CDC that ranks and scores research around workplace wellness interventions)
- The average required time spent studying nutrition in medical schools fell from 22.3 hours in 2004 to 19.6 hours in 2008-9 (this explains why I tell people, “don’t ask me, they didn’t teach us that in medical school”)*
There are innovations like the Healthy Kids Healthy Future Childcare Guidelines, the Y’s Diabetes Prevention Program funded by a private insurer (UnitedHealth Group) and tied to performance, not just participation, the National Restaurant Association’s Kids LiveWell program, that has nutritional standards adopted by 15,000 restaurants, joint use agreements that allow school properties to be used for after-hours physical activity programs and parks and recreation to used for physical fitness programs in schools.
The report is appropriately realistic about the impacts and funding sources of all of these initiatives and doesn’t paint an overly rosy picture. Believe me, there are plenty of disturbing pieces of data about our health, the change in our lifestyles that’s been happening over the past 50 years, and the policies and approaches that conspire to prevent us from being well.
I think the way to take advantage of what’s in here is to go through it and find the 5-6 things that interest you or are relevant to you in your work. It could be the $12 billion that health care institutions spend on food and beverages, it could be the tax status of health investments versus medical costs in health savings accounts, I’m confident that anyone interested in this issue will find something actionable.
While there are plenty of journal articles, reports, and thick binders of this type of information, what I like about the approach here is the tying together of the individual, family, community, society in a way that’s relevant to people in the United States. Changing the perspective of the building of a sidewalk from a transportation strategy to a diabetes prevention strategy is very much in the scope of our culture. I wouldn’t go so far to say that it’s our Marmot Review (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review | Ted Eytan, MD) , but it’s a good companion to it :).
No easy policy prescriptions exist because solutions to the problem depend on choices about diet and physical activity that are ultimately personal; they come down to the messages parents send their kids, the decisions people make in the supermarket aisle, and everyone’s willingness and ability to look out for his or her own health. But it is equally critical to recognize that individual choices take place in a context and are powerfully shaped by a host of external influences. That means government and other institutions have an important role to play in ensuring that all citizens have at least the information and the opportunity to pursue a healthy lifestyle.
As I always say, I’m not that smart and my ideas are not that unique. There is plenty to learn, plenty to grab on to, and an understanding that focusing on a specific person’s choices as the answer is not the answer – that’s the bad news. It’s also the good news – focusing on a specific person’s choices as the answer is not the answer. Let’s innovate.